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Park County Chiropractic Child History Form

Park County Chiropractic Child History Form

Our  Mission is to help you to Better Health and Better Function so you can have more Possibilities

HIPAA

Compliance

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    HIPAA Notification - Please Read and Sign Below
    Park County Chiropractic believes in protecting your private health information and we are in accordance with the Health Insurance Portability and Accountability act of 1996 (HIPAA). If you would like to have the full privacy policy, it is available for review.
    Treatment, Payment, Health Care Operations: You should be aware that during the course of our relationship, we could use and disclose heath information about you for treatment, payment, and healthcare operations.
    Examples of these activities are as follows:

    • Treatments: We may use or disclose your health information to other health care providers providing treatment to you.
    • Payment: We may use and disclose your health information to obtain payment for services we provide to you.
    • Health care operations: We may use and disclose your health information in connection with our health care operations. Health care operations include clinical education, quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and employee performance and other business operations.
    • Contacting You: We may contact you by phone, text, email, or postal service for health related matters and thank you notices. Messages may be left on an answering machine, voice mail, or with a person answering your specific phone number(s).

    Authorization: You may specifically authorize us to use your health information for any purpose or to disclose your health information to anyone by submitting such an authorization in writing. Upon receiving an authorization in writing from you, we may use or disclose your health information in accordance with that authorization. You may revoke an authorization at any time by notifying us in writing. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those permitted by this Notice or Law.

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  • 2

    Please read this entire page prior to signing it. It is important that you understand the information contained in this document.

    The Nature of the Chiropractic Adjustment

    The primary treatment used as a Doctor of Chiropractic is spinal manipulative therapy. This procedure will likely be used to treat you. It may be with the use of hands or a mechanical instrument upon your body in such a way as to move your joints. That may feel a sense of movement or release.

    As a part of the analysis, examination, and treatment, you are consenting to the following procedures:

    Analysis and Examination Procedures:

    Vital signs (Temp, BP, etc) Postural analysis testing
    Palpation (feeling muscles/joints) Neurological examination
    Range of motion testing Order blood labs
    Muscle strength testing Order of Imaging
    Orthopedic testing Urine analysis
    Body composition analysis  

    Treatments:

    Spinal Manipulative Therapy (Chiropractic Adjustment) Hot/Cold Therapy
    Ultrasound (Therapeutic) Electrical Muscle Stimulation
    Functional Dry Needle Therapy Taping/Joint Support Procedures
    Soft Tissue Manipulation/Mobilization by hand or instrument Rehabilitation/Exercise Therapies
    Nutritional, Herbal Therapeutics  

    The material risks inherent in chiropractic treatment and other treatments: As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, accidental puncture of a lung (dry needling) light bruising and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. This is extremely rare. Some patients will feel some stiffness and soreness following the first few days of treatment. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me.

    The probability of those risks occurring: Fractures are rare occurrences and generally result from some underlying weakness of the bone which will be checked for during the taking of your history and during examination and/or X-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.

    The availability and nature of other treatment options: Other treatment options for your condition may include:

    • Self-administered, over-the-counter analgesics and rest
    • Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers
    • Hospitalization
    • Surgery

    If you chose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.

    The risks and dangers attendant to remaining untreated:  Remaining untreated may allow the formation of adhesions and reduce mobility and stability which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed. More extensive interventions may become required or necessary.

     
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    I * have read the above explanation of the chiropractic adjustment and related treatment(s). I will discuss any questions I have with Dr Dobelbower.
    By signing below, I state that I have weighed the risks involved in undergoing treatment and have decided it is in my best interest to undergo the treatment. Having been informed of the risk, I hereby give my consent to treatment.
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    If different from Legal Name
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    This is private information. It will only be used to help provide appropriate health care to you.
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    We will not sell or give anyone this phone number!
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    We will not sell your number to anyone. This is part of your private health information.
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    We will not sell your number to anyone. This is part of your private health information.
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    We will not sell this address to anyone. This is part of your private health information
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    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
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    • Other
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    Describe what you do, not where you work.
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    Please select from the drop down list
    • Friend or Family Member
    • Local Gym
    • Medical Doctor
    • Massage or Physical Therapist
    • Website
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    * recommended Park County Chiropractic for your child. May we thank them for the referral?    *         

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    * recommended Park County Chiropractic for your child.  May we contact them to coordinate care?           
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    Select ALL that apply
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    How & When
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    • Morning
    • Afternoon
    • Evening
    • Night (after dark)
    • From the Front
    • From the Back
    • From the Left
    • From the Right
    • Other
    • The Front Passenger
    • Backseat Passenger on right
    • Backseat Passenger on left
    • In a child Safety Seat
    • Not In A Vehicle
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    Please Select
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    • Yes
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    Select All that apply
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    1 of 3
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    Please Select
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    • Yes
    • No
    • None Performed
    • X-Rays
    • MRI
    • CT
    • Unsure
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    You will be billed for services until we have the required information on this page
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    How & When
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    • Yes, They have filled out forms
    • Yes, They have not filled out forms
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    Select All that apply
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    • Yes
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    • X-Rays
    • MRI
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    You will be billed for services until we have the required information on this page
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    Please Select
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    • Yes
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    • Sometimes
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    Select All that apply
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    Please Select
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    • Yes
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    Select All That Apply
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    Please Tell Us Where So Your Child's Records Can Be Requested
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    Please mark the area of pain and radiation
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  • 49
    0 - 10 Scale
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  • 50
    List Your Goals
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  • 51
    Prescription or OTC
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    Please be thorough as possible
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    Please be as thorough as possible
    Please Select
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    • General Health
    • Athletic Performance
    • Heart Disease
    • High Blood Pressure
    • Gall Bladder
    • Heart Burn/Gerd
    • Thyroid
    • Pain
    • Asthma
    • Diabetes
    • Mental Health
    • Other
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    • General Health
    • Athletic Performance
    • Heart Disease
    • High Blood Pressure
    • Gall Bladder
    • Heart Burn/Gerd
    • Thyroid
    • Pain
    • Asthma
    • Diabetes
    • Mental Health
    • Other
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    • General Health
    • Athletic Performance
    • Heart Disease
    • High Blood Pressure
    • Gall Bladder
    • Heart Burn/Gerd
    • Thyroid
    • Pain
    • Asthma
    • Diabetes
    • Mental Health
    • Other
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    Liquids
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    Activity
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    Please Select
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    • Less than 1
    • 1-2 Packs/Day
    • 2-3 Packs/Day
    • 3+ Packs/Day
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    • Yes
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    • Maybe
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    Select ALL that apply
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    Please Select
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    • Yes
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  • 73
    Select ALL that apply
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    Teacher or other care providers words or your concerns
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    They eat whole foods
    They avoid processed foods
    They sleep 7-9 hour/night
    They exercise 3+ hrs/week
    They poop at least 1x/day
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    Move the foods on the right to the left if
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  • 78
    Please Select
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    • Excessive
    • Irregular
    • Painful/Cramping
    • Light
    • No Longer Applies
    • Painful/Swollen Breasts
    • Emotional Up/Downs
    • Bloating
    • Brain Fog
    • Back/Leg Pain
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    Select ALL that apply
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    Select ALL that apply
    1 of 6
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    Please provide Front and Back of your card
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  • 82

    Healthy Montana Kids, Medicaid, or Personal Injury
    I authorize and direct payment be made to:
    Park County Chiropractic 1201 US Hwy 10 W Ste A1 Livingston, MT 59047
    For any and all benefits or reimbursement for services rendered by Dr Dobelbower or his assistants which amounts would otherwise be payable to me under any insurance or pre-paid health care plan. I understand I am responsible for payment of all deductible and/or co-payments and non-covered services at the time services are rendered.
    By signing, I agree to the above information.        Pick a Date    

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  • 83

    Payment Agreement
    I understand and agree all services rendered to my child are charged directly to me and that I am personally responsible for payment.
    I understand Park County Chiropractic and it's doctors do not accept assignment from major medical insurance policies.
    I understand that there is no guarantee that my insurance company or health plan will cover or pay for any charges.
    I understand that all charges for services rendered to me or my dependent are due at the time services are rendered unless other arrangements are made.
    It is my responsibility to pay for services rendered without receiving billings statements.
    Rescheduling Policy
    Our goal is to provide quality individualized health care in a timely manner. Not showing up or late rescheduling inconveniences other people (who might be in pain) needing access to health care in a timely manner. We ask YOU to be respectful of the health care needs of other people and promptly call if your child is unable to keep an appointment. If it is necessary to reschedule your child's appointment, we require AT LEAST 24 HOURS NOTICE. WE RESERVE THE RIGHT TO CHARGE $30 FOR MISSED APPOINTMENTS WITH LESS THAN 24 HOURS NOTICE.

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  • 84

    Parent Consent for Treatment of Minor Child:
    I hereby authorize Dr Stephen Dobelbower and whomever the doctor may designate as assistants to administer Chiropractic care, rehab, functional movement, and other appropriate therapies as the doctor deems necessary to my child.

    By signing below, you are stating the information you have filled in this form is true and correct to be best of your ability. You understand your privacy rights, your payment responsibility, and Park County Chiropractic's rescheduling policy. You and your child will have the opportunity to ask questions and address concerns with the treating doctor prior to treatment. We look forward to meeting you and your child!
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